Arterial thrombosis and intracardiac thrombus as the initial presentation of a recurrent paraganglioma: case report and review of the literature

SUMMARY Pheochromocytomas and paragangliomas (PPGL) are rare neuroendocrine tumors that result in the uncontrolled release of catecholamines and secondary hypertension. They usually manifest with episodic blood pressure fluctuations, headaches and palpitations. In some cases PPGLs may be asymptomatic until they are detected as a diagnostic approach to other diseases. There have been reports that have associated PPGLs with arterial thrombosis, some with the additional finding of intracardiac thrombi. We present the case of a 21-year-old male Hispanic patient with a recurrent para-aortic paraganglioma detected by persistent hypertension, bilateral lower limb artery thrombosis and an intracardiac thrombus.

Arterial thrombosis and intracardiac thrombus as the initial presentation of a recurrent paraganglioma: case report and review of the literature.

Pheochromocytomas and paragangliomas (PPGL) are rare neuroendocrine tumors that result in the uncontrolled release of catecholamines and secondary hypertension. They usually manifest with episodic blood pressure fluctuations, headaches and palpitations. In some cases PPGLs may be asymptomatic until they are detected as a diagnostic approach to other diseases. There have been reports that have associated PPGLs with arterial thrombosis, some with the additional finding of intracardiac thrombi. We present the case of a 21-year-old male Hispanic patient with a recurrent para-aortic paraganglioma detected by persistent hypertension, bilateral lower limb artery thrombosis and an intracardiac thrombus.

[Long-term efficacy of parathyroidectomy in secondary and tertiary hyperparathyroidism]. / Eficacia a largo plazo de la paratiroidectomía en hiperparatiroidismo secundario y terciario.

BACKGROUND: Secondary and tertiary hyperparathyroidism (SHPT and THPT), are complications of chronic kidney disease (CKD), characterized by high levels of serum parathormone, hyperphosphatemia or hypercalcemia, respectively. If diet and pharmacological therapies fail, clinical practice guidelines suggest parathyroidectomy (PTX). Some studies have described its effectiveness and safety, but these have not included Mexican population. OBJECTIVE: To describe long-term effectiveness of PTX in Mexican patients with SHPT or THPT. MATERIAL AND METHODS: Observational and retrospective study of patients treated with PTX between 1995 and 2014 in a third level hospital in Mexico City. The analyses included the follow-up of medical treatment and biochemical assessment every three months during the first year, and the last evaluation. Permutation and chi square tests were used. RESULTS: The study included 27 patients (14 women). The follow-up mean was 39 months; 61.5% had SHPT. All biochemical parameters, except magnesium, were reduced in the first year of follow-up. In the long term, SHPT was controlled in 80% using PTH under a 300 pg/mL criterion, and 90% in patients with THPT using calcium criterion. Persistent hypocalcemia was present in 11.5% of cases. CONCLUSION: Mexican patients with SHPT and THPT could be successfully treated with surgery with low risk of hypocalcemia.

INTRODUCCIÓN: el hiperparatiroidismo secundario (SHPT) y terciario (THPT) son complicaciones de la enfermedad renal crónica (ERC), caracterizadas por elevación de hormona paratiroidea, hiperfosfatemia o hipercalcemia. Si la terapia nutricional y farmacológica fallan, se sugiere la paratiroidectomía (PTX). Los estudios de cohorte que han descrito su efectividad no incluyen a la población mexicana. OBJETIVO: describir la efectividad a largo plazo de la PTX en pacientes mexicanos con SHPT y THPT. MATERIAL Y MÉTODOS: estudio observacional, retrospectivo de pacientes tratados con PTX entre 1995 y 2014 en un hospital de tercer nivel de la Ciudad de México. Se registraron la terapia médica, la evaluación bioquímica, cada tres meses durante un año, y la última evaluación registrada. Se utilizaron pruebas de permutación y de chi cuadrada. RESULTADOS: se incluyeron 27 pacientes (14 mujeres). El seguimiento promedio fue de 39 meses; 61.5% tuvieron SHPT. Los parámetros bioquímicos, salvo el magnesio, disminuyeron durante el primer año postquirúrgico. A largo plazo, el SHPT fue controlado en 80%, con el criterio de la PTH menor de 300 pg/mL, y el THPT en el 90% con el criterio de normocalcemia. La hipocalcemia permanente estuvo presente en 11.5% de los casos. CONCLUSIÓN: los pacientes mexicanos con SHPT y THPT pueden ser tratados exitosamente mediante cirugía con bajo riesgo de hipocalcemia.

Neutral protamine hagedorn/regular insulin in the treatment of inpatient hyperglycemia: Comparison of 3 basal-bolus regimens.

AIM: To compare the safety and efficacy or 3 basal-bolus regimens of neutral protamine hagedorn (NPH)/regular insulin in the management of inpatient hyperglycemia. METHODS: We randomized 105 patients with blood glucose levels between 140 and 400 mg/dL to a basal-bolus regimen of NPH insulin given once (n = 30), twice (n = 40) or three times (n = 35) daily, in addition to pre-meal regular insulin. Major outcomes included were differences in glycemic control, frequency of hypoglycemia and total insulin dose. RESULTS: NPH insulin given in a once-daily regimen was associated with better glycemic control (58.3%) compared to twice daily (42.4%) and three times daily (48.9) regimens (P = 0.031). The frequency of hypoglycemia was similar between the three groups (2.0%, 0.7% and 1.2%, P = 0.21). The mean insulin dose at discharge was 0.48 ± 0.14 U/kg in the once-daily group compared to 0.69 ± 0.28 in the twice-daily, and 0.65 ± 0.20 in the three times daily regimens (P < 0.001). CONCLUSION: NPH insulin administered in a once-daily regimen resulted in improvement in glycemic control with similar rates of hypoglycemia compared to a twice-daily and a three times-daily regimen. Further studies are needed to evaluate whether this regimen could be implemented in all hospitalized patients with hyperglycemia.

Steroid hyperglycemia: Prevalence, early detection and therapeutic recommendations: A narrative review.

Steroids are drugs that have been used extensively in a variety of conditions. Although widely prescribed for their anti-inflammatory and immunosuppressive properties, glucocorticoids have several side effects, being hyperglycemia one of the most common and representative. In the present review, we discuss the main epidemiologic characteristics associated with steroid use, with emphasis on the identification of high risk populations. Additionally we present the pathophysiology of corticosteroid induced hyperglycemia as well as the pharmacokinetics and pharmacodynamics associated with steroid use. We propose a treatment strategy based on previous reports and the understanding of the mechanism of action of both, the different types of glucocorticoids and the treatment options, in both the ambulatory and the hospital setting. Finally, we present some of the recent scientific advances as well as some options for future use of glucocorticoids.

Clinical course of diabetic ketoacidosis in hypertriglyceridemic pancreatitis.

OBJECTIVES: Hypertriglyceridemic pancreatitis (HP) is an uncommon condition accounting for 1% to 4% of cases of acute pancreatitis, mostly associated with poor glycemic control. Diabetic ketoacidosis (DKA) may complicate the clinical course of HP. Our objective was to identify clinical and demographic differences between HP and DKA patients compared with those without DKA. METHODS: Fifty-five patients with HP were included. Diabetic ketoacidosis was diagnosed in 8 patients. We analyzed the severity, hospital stay, delay in oral intake, duration of insulin infusion, complete blood cell count, and triglyceride levels. RESULTS: Diabetic ketoacidosis was associated with a more severe HP. There were no differences in hospital stay, delay in oral intake, or duration of insulin treatment in both groups. Serum amylase, lipase, and triglyceride levels were similar. Previous diagnosis of diabetes mellitus, higher Ranson and APACHE II scores, and higher serum glucose level at admission were the only predictive risk factors for DKA and HP. CONCLUSIONS: Coexistence of DKA does not modify the clinical course of HP, although a more severe episode of HP in DKA patients. Diabetic ketoacidosis was associated with higher insulin doses, without impact in triglyceride levels. Diabetic ketoacidosis and HP should be considered when a previous diagnosis of diabetes mellitus and a severe HP are present.

Acute Pancreatitis and Diabetic Ketoacidosis following L-Asparaginase/Prednisone Therapy in Acute Lymphoblastic Leukemia.

Acute pancreatitis and diabetic ketoacidosis are unusual adverse events following chemotherapy based on L-asparaginase and prednisone as support treatment for acute lymphoblastic leukemia. We present the case of a 16-year-old Hispanic male patient, in remission induction therapy for acute lymphoblastic leukemia on treatment with mitoxantrone, vincristine, prednisone, and L-asparaginase. He was hospitalized complaining of abdominal pain, nausea, and vomiting. Hyperglycemia, acidosis, ketonuria, low bicarbonate levels, hyperamylasemia, and hyperlipasemia were documented, and the diagnosis of diabetic ketoacidosis was made. Because of uncertainty of the additional diagnosis of acute pancreatitis as the cause of abdominal pain, a contrast-enhanced computed tomography was performed resulting in a Balthazar C pancreatitis classification.

Glucose disturbances in non-diabetic patients receiving acute treatment with methylprednisolone pulses.

OBJECTIVE: Methylprednisolone pulses are used in a variety of disease conditions, both for acute and chronic therapy. Although well tolerated, they increase glucose levels in both non-diabetic and diabetic patients. They may also be considered a significant risk for acute metabolic alterations. The purpose of this report is to determine the metabolic changes in blood glucose levels in non-diabetic patients receiving methylprednisolone pulses and identify the presence of predictive factors for its development. METHODS: Observational, prospective study in 50 non-diabetic patients receiving 1 g intravenous methylprednisolone pulses for three consecutive days as an indication for diverse autoimmune disorders. Demographic, anthropometric, and metabolic variables were analyzed, and glucose, insulin and C-peptide levels after each steroid pulse were identified. Different variables and the magnitude of hyperglycemia were analyzed using Pearson's correlation. RESULTS: 50 patients were included, predominantly women (66%, n = 33). The average age was 41 ± 14 years with a BMI of 26 ± 3 kg/m². Baseline glucose was 83 ± 10 mg/dL. After each steroid pulse, glucose increased to 140 ± 28, 160 ± 38 and 183 ± 44, respectively (p < 0.001). C-peptide and insulin concentrations increased significantly (p < 0.001). The prevalence of fasting hyperglycemia after each pulse was 68%, 94% and 98%, respectively. We found no correlation between the magnitude of hyperglycemia and the studied variables. CONCLUSION: Methylprednisolone pulses produced significant increases in fasting glucose in most patients without diabetes. Further studies are needed to define its role in long-term consequences.

Glucose disturbances in non-diabetic patients receiving acute treatment with methylprednisolone pulses / Distúrbios de glicose em pacientes não diabéticos que recebem tratamento agudo com pulsos de metilprednisolona

OBJECTIVE: Methylprednisolone pulses are used in a variety of disease conditions, both for acute and chronic therapy. Although well tolerated, they increase glucose levels in both non-diabetic and diabetic patients. They may also be considered a significant risk for acute metabolic alterations. The purpose of this report is to determine the metabolic changes in blood glucose levels in non-diabetic patients receiving methylprednisolone pulses and identify the presence of predictive factors for its development. METHODS: Observational, prospective study in 50 non-diabetic patients receiving 1 g intravenous methylprednisolone pulses for three consecutive days as an indication for diverse autoimmune disorders. Demographic, anthropometric, and metabolic variables were analyzed, and glucose, insulin and C-peptide levels after each steroid pulse were identified. Different variables and the magnitude of hyperglycemia were analyzed using Pearson's correlation. RESULTS: 50 patients were included, predominantly women (66 percent, n = 33). The average age was 41 ± 14 years with a BMI of 26 ± 3 kg/m². Baseline glucose was 83 ± 10 mg/dL. After each steroid pulse, glucose increased to 140 ± 28, 160 ± 38 and 183 ± 44, respectively (p < 0.001). C-peptide and insulin concentrations increased significantly (p < 0.001). The prevalence of fasting hyperglycemia after each pulse was 68 percent, 94 percent and 98 percent, respectively. We found no correlation between the magnitude of hyperglycemia and the studied variables. CONCLUSION: Methylprednisolone pulses produced significant increases in fasting glucose in most patients without diabetes. Further studies are needed to define its role in long-term consequences.

OBJETIVO: Pulsos de metilprednisolona são usados em diversas doenças, tanto para tratamento agudo quanto crônico. Embora bem tolerados, eles aumentam os níveis de glicose em ambos os pacientes, não diabéticos e diabéticos. Eles também podem ser considerados um risco significativo para alterações metabólicas agudas. O propósito deste estudo é determinar as alterações metabólicas nos níveis de glicose no sangue de pacientes não diabéticos que recebem pulsos de metilprednisolona e identificar a presença de fatores preditivos para seu desenvolvimento. MÉTODOS: Estudo observacional prospectivo em 50 pacientes não diabéticos que recebem pulsoterapia com 1 g de metilprednisolona intravenosa por três dias consecutivos como tratamento para diversas doenças autoimunes. Variáveis demográficas, antropométricas e metabólicas foram analisadas, e glicose, insulina e níveis de peptídeo C foram identificados após cada pulso de esteroide. Diferentes variáveis e a magnitude da hiperglicemia foram analisadas utilizando a correlação de Pearson. RESULTADOS: 50 pacientes foram incluídos, predominantemente mulheres (66 por cento, n = 33). A idade média foi de 41 ± 14 anos com um IMC de 26 ± 3 kg/m². A glicose de base foi de 83 ± 10 mg/dL. Após cada pulso de esteroide, a glicose aumentou para 140 ± 28, 160 ± 38 e 183 ± 44, respectivamente (p < 0,001). Peptídeo C e concentrações de insulina aumentaram significativamente (p < 0,001). A prevalência de hiperglicemia em jejum após cada pulso foi de 68 por cento, 94 por cento e 98 por cento, respectivamente. Não encontramos nenhuma correlação entre a magnitude da hiperglicemia e as variáveis estudadas. CONCLUSÃO: Os pulsos de metilprednisolona produziram aumentos significativos na glicemia de jejum na maioria dos pacientes sem diabetes. Mais estudos são necessários para definir o seu papel nas consequências em longo prazo.